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Learning Objectives
Program participants will be able to:
List the three overall goals of the SNP Model of Care Describe the three qualifying medical conditions for patients in
the Health Net Jade C-SNPs Understand the important components of the care plan and
team based care to improve care coordination for SNP patients Name two principles important to improve transition care
management Identify three outcomes being measured to evaluate the Model
of Care
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Special Needs Plan (SNP) Background
SNPs are Medicare Advantage plans with special benefit packages for populations with distinct health care needs. Goal is to provide extra benefits and team-based care to improve outcomes and decreasecosts for special need population through improved coordination. There are 3 SNP types:
Dual Eligible or D-SNP for those eligible for Medicare and Medicaid Chronic Disease or C-SNP for those with severe or disabling
chronic conditions – provider attestation of condition required Institutional or I-SNP for those requiring institutional level of care or
equivalent living in the community (Health Net does not have this type)
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Goals of Special Needs PlansImprove Access Improving access to medical and mental health and social services Improving access to affordable care and preventive health servicesImprove Coordination Improving coordination of care through an identified point of contact Improving transitions of care across health care settings, providers
and health services Assuring appropriate utilization of servicesImprove Outcomes Improving patient health outcomes
Model of Care 1
SNP PopulationGeneral PopulationVulnerable Subpopulations
Section 2
5Confidential and Proprietary Information
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Health Net SNPs Health Net has two types of SNPs: D-SNPs for patients that are dually eligible for Medicare and Medicaid
known as the Amber SNPs
C-SNPs for patients with chronic and disabling disorders known as the Jade SNPs - one or more of the following chronic diseases is required and must be documented/attested to depending on specific SNP:
1. Diabetes
2. Chronic Heart Failure
3. Cardiovascular Disorders (CV): Cardiac ArrhythmiasCoronary Artery DiseasePeripheral Vascular DiseaseChronic Venous Thromboembolic Disorder
Vulnerable SNP Sub-Populations
Populations at greatest risk are identified to direct resources towards patients with increased need for team based care:
Complex/multiple chronic conditions – require assistance with disease management and navigating health care systems
Disabled - unable to perform key functional activities independently Frail – over 85 years and/or diagnoses such as osteoporosis,
rheumatoid arthritis, COPD, CHF Cognitively Impaired – at risk due to moderate/severe memory loss End-of-Life – those with terminal diagnosis
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Benefits to Meet Specialized Needs
Decision Power Disease Management – whole person approach to wellness with comprehensive in-person, online and written educational and interactive health resources
Medication Therapy Management – pharmacist review ofmedication profile quarterly and communication with member/doctor when issues identified: duplications, interactions, gaps in treatment, adherence
Transportation – covers medically related trips up to unlimited under the health plan or Medicaid benefit and vary according to the specific SNP and region
In addition, SNP may have benefits for Dental, Vision, Podiatry, Gym Membership, Hearing Aides, OTC allowance or lower costs for items such as Diabetic Monitoring supplies, Cardiac Rehabilitation – these benefits vary by region/SNP type
SNP Member Diversity
9Confidential and Proprietary Information
83%
3%
3%3%
1.5% 0.5% 6%
Reported Non-English Languages (CA)
SpanishChineseVietnameseTagalogKoreanJapaneseOther
Language/Communication Resources
SNP patients may have greater incidence of limited English proficiency, health literacy issues and disabilities that affect communication and impact health outcomes.
Office interpretation services- in-person and sign-language with minimum of 3-5 days notice
Health Literacy - training materials and in-person training available
Cultural Engagement – training materials and in-person training available
Vital documents translated or alternate format provided 711 relay number for hearing impaired
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Communication SystemsMultiple communication systems to implement the SNP care coordination requirements: An Electronic Medical Management System for documentation
of case management, care planning, input from the interdisciplinary team, transitions, assessments and authorizations
A Customer Call Center to assist with enrollment, eligibility and coordination of benefit questions and meet individual communication needs (language or hearing impairment)
A secure Provider Portal to communicate member information to SNP delegated medical groups
A Member Portal for access to online health education, interactive programs and the ability to create a personal health record
Member and Provider Communications such as member and provider newsletters and educational outreach may be distributed by mail, phone, fax or online
SNP Population Special Needs
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0%
20%
40%
60%
80%
100%
DifficultyWalking
ImpairedVision
MemoryIssues
HearingProblems
Member Reported
Care Coordination: Case Management Health Risk AssessmentsIndividualized Care PlanInterdisciplinary Care Team Care Transitions
Section 3
Model of Care 2
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Patient Centric
Patient is informed of and consents to Case Management
Patient participates in development of their Care Plan
Patient agrees to the goals and interventions of their Care Plan
Patient informed of Interdisciplinary Care Team (ICT) members and meetings
Patient either participates in the ICT meeting or provides input through the Case Manager and informed of outcomes
Patient satisfaction with the SNP Program is measured annually
Evidence Based Case Management (CM)
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All SNP patients enrolled in case management and notified of CM single point of contact by letter/follow-up phone call
Patients may opt out of active case management but Case Manager continues to attempt an annual contact or when change in status or transition in care.
Patients are stratified according to their risk profile and/or Health Risk Assessment (HRA) to focus resources on most vulnerable
Patients with only a behavioral health diagnosis (drug/alcohol, schizophrenia, major depressive, bipolar/paranoid) receive primary case management from MHN, the Behavioral Health provider
Contingency planning is in place to avoid disruption of services for events such as disasters
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Roles of the Case Manager:
Performs a health risk assessment of medical, psychosocial, cognitive and functional status
Develops a comprehensive individualized care plan with member input
Identifies barriers to goals and strategies to address
Discusses member care at Interdisciplinary Care Team (ICT) meetings.
Provides personalized education for optimal wellness
Encourages preventive care and closure of care gaps such as cancer screening, vaccines
Reviews and educates on medication regimen
Promotes appropriate utilization of benefits
Assists member to access community resources
Assists caregiver when member is unable to participate
Assesses cultural and linguistic needs and preference
Coordinates care with primary care physician
94% of members report overall satisfaction with CM
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Health Risk Assessment (HRA)
An HRA is conducted to identify medical, psychosocial, cognitive, functional and mental health needs and risks
Health Net attempts to complete initial HRA telephonically within 90 days of enrollment and annually or if there is a significant change or transition of care
Multiple attempts are made to complete HRA including mailed surveys and e-mail reminders
The HRA responses are used to identify needs, incorporated into the care plan and communicated to the care team
Reassessments when there is a change in health condition and and annual updates are used to update the care plan
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Encourage patients to complete HRA over telephone or by mail
Explain the information helps the Case Manager and ICT to meet their healthcare needs
Register for and check the provider portal regularly for new HRAs
Use the HRA responses to stratify patient outreach
HRA is mailed to non-delegated provider groups
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Individualized Care Plan (ICP)Created for each patient by the Case Manager with input from the care team. The patient and/or caregiver is involved in and agrees with the care plan and goals:
Based on the patient’s assessment and identified problems Goals are prioritized considering patient's personal preferences
and desired level of involvement in the process Updated when change such as new diagnosis/hospitalization or
at least annually and communicated to ICT and patient Accessible/shared with members of the ICT including patient and
provider Includes patient’s self-management plans and goals Includes description of services tailored to patient’s needs Includes barriers and progress towards goals
ICP Must Address All Risks Identified in HRA and/or Other Sources
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HRA/Assessment/ Claims
Risks
Medical HistoryGap ReportsUtilization Reports
DiabetesObesityLack of medication adherenceRecent ER visit for fall
Labwork/ biometrics HgA1c - 9BMI – 31
Mental Health Positive depression screen
Health Behaviors Does not get annual Flu vaccine
Psychosocial No transportation to Dr. appts
ICP Goals for Each Risk Must be Specific, Measureable and Include Date to be Achieved
Risk Specific and Measurable Goal Established with Patient
Poor Medication Adherence
Patient will report taking diabetes medications daily at each monthly call and will not be on care gap list by March.
Positive Depression Screen
Patient will report discussing emotional health with PCP at next doctor appointment on April 20th.
Obesity – BMI Patient will lose 5 pounds over next 6 months
Fall Risk Patient will report going to gym once per week during monthly calls
Lack of Annual Flu vaccine
Patient will get flu vaccine by November 1.
Lack of transportation
Patient will successfully utilize transportation benefit for next doctor appointment on April 20th
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ICP Must Include Actions to Achieve Goals
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Risks Actions to Achieve Goals
Poor control of DiabetesObesityPoor medication adherenceRecent ER visit for fall
Provide Diabetes and diet education. Set exercise and weight loss goals with patient Review medication regime and provide adherence tips to address individual barriers Fall prevention education and to discuss with doctor
HgA1c - 9BMI – 31
Monitor lab work and weight for improvement
Positive depression screen Referral to MHN
Does not get annual Flu vaccine
Educate on importance of vaccine, address barriers to obtaining vaccine
No transportation to Dr. appts
Educate on benefit and provide contact information
Must Document Care Plan ImplementationRisk Case Manager NotesPoor Control of Diabetes
2/15/XX Reviewed diet with patient – she reports eating smaller portions since last call and diet education.
Poor Medication Adherence
1/15/XX Review of diabetes medications and proper admin–patient verbalizes understanding. Encouraged to use pill box.
Positive Depression Screen
3/21/XX Patient refused referral to MHN – states she will discuss with her doctor at April visit.
Obesity – BMI 4/21/XX Patient states she only lost 2 lbs at Doctor visit yesterday. Reviewed concept of steady and slow weight loss.
Fall Risk 2/15/XX Patient reports she is taking 15 minute walk once a day and will increase to 20 minutes next week.
Lack of Annual Flu vaccine
9/15/XX Review of importance of Flu vaccine – patient still concerned it will make her sick. Addressed barriers.
Lack of transportation
3/21/XX Patient has contacted transportation company and arranged ride to 4/20 Dr. appointment
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Interdisciplinary Care Team (ICT)The Health Net, MHN or delegated Case Manager coordinates the ICT with regular communication to manage the patient's medical, cognitive, psychosocial and functional needs. The patient and/or caregiver is included on the ICT whenever possible:
Required Team Members: Medical Expert Social Services Expert Mental/Behavioral Health Expert – when indicated
Additional Team Members could be: Pharmacist Health Educator/Disease Management Restorative Therapist Nutrition Specialist
Communication plan for regular ICT exchange of information including accommodations for patients with sensory, language or cognitive barriers
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Care Transition Protocols
Patients are at risk of adverse outcomes when transitioning between settings (hospital, nursing home, rehabilitation center, outpatient surgery centers or home health). Patients experiencing an inpatient transition are identified and
managed (pre-authorization, facility notification, census) Important elements (diagnoses, medication reconciliation, treatments,
providers and contacts) of the care plan transferred between care settings before, during and after a transition
Patient able to communicate their health information to healthcare providers in different settings
Patient informed of health status and self-management skills: discharge needs, meds, follow-up care, signs of change and how to respond (discharge instructions, post-discharge calls)
Provider Network: Specialized Provider NetworkClinical Practice GuidelinesModel of Care Training
Section 4
Model of Care 3
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Specialized Provider Network
Health Net maintains a comprehensive network of primary care providers and specialists such as cardiologists, neurologists and behavioral health practitioners to meet the health needs of chronically ill, frail and disabled SNP patients
Team based case management is provided by Health Net when it is not delegated to the patient’s primary care provider and medical group
Delegated medical groups must demonstrate capability to meet the team based care requirements
The Delegation Oversight team conducts regular audits to monitor that delegated medical groups meet the SNP Model of Care requirements
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Jade C-SNPs – Chronic Heart Failure and Cardiovascular Disease
Disease Management to assist patients to manage their Cardiovascular disease
Additional benefits (vary by plan) can include zero cost cardiac rehab services
Clinical Practice Guidelines for Chronic Heart Failure located on the Provider Portal
In addition to a Provider Network with practitioners and specialists skilled in managing patients with Cardiovascular Disease, the program has available:
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Jade C-SNPs – Diabetes
Disease Management to assist patients to manage their Diabetes
Interactive programs for healthy activity and weight control
Additional benefits (vary by plan) can include zero cost for Diabetic monitoring supplies, low cost Podiatrist visits
Clinical Practice Guidelines for Diabetes and other chronic diseases located on the Provider Portal
In addition to a Provider Network with practitioners and specialists skilled in managing patients with Diabetes, the program has:
Click below to see the to Health Net/Centene:
Clinical Practice Guidelines
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D-SNPs -Coordinating Medicare and MedicaidThe goals of coordination of Medicare and Medicaid benefits for members that are dual-eligible:
Members informed of benefits offered by both programs Members assisted to maintain Medicaid eligibility Member access to staff that has knowledge of both programs Clear communication regarding claims and cost-sharing from
both programs Coordinating adjudication of Medicare and Medicaid claims
when Health Net is contractually responsible Members informed of rights to pursue appeals and grievances
through both programs Members assisted to access providers that accept Medicare
and Medicaid
Quality Improvement: Measureable GoalsEvaluation of PerformanceCommunicates Progress Towards Goals
Section 5
Model of Care 4
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Quality Improvement ProgramHealth Plans offering a SNP must conduct a Quality Improvement program to monitor health outcomes and implementation of the Model of Care by:
Identifying and defining measurable Model of Care goals and collecting data to evaluate annually if measurable goals are met
Collecting SNP specific HEDIS® measures Conducting a Quality Improvement Project (QIP) annually that focuses
on improving a clinical or service aspect that is relevant to the SNP population (Diabetes Prevention)
Providing a Chronic Care Improvement Program (CCIP) that identifies eligible members, intervenes to improve disease management and evaluates program effectiveness (Osteoporosis Management)
Communicating goal outcomes to stakeholders
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Data Collection
Health Outcomes
Access To Care
Improved Health Status
Implementation Of MOC
Health Risk Assessment
Implementation Of Care Plan
Provider Network
Continuum Of Care
Delivery Of Extra Services
Communication Systems
Data is collected, analyzed and evaluated from multiple domains of care to monitor performance and identify areas for improvement:
SNP HEDIS® Measures
Colorectal Cancer Screening
Spirometry Testing for COPD Pharmacotherapy
Management of COPD Exacerbations
Controlling High Blood Pressure
Persistence of Beta-Blockers after Heart Attack
Osteoporosis Management Older Women with Fracture
Medication Reconciliation Post-Discharge
All Cause Readmission
Antidepressant Medication Management
Follow-Up After Hospitalization for Mental illness
Annual Monitoring for Persistent Medications
Potentially Harmful Drug Disease Interactions
Use of High Risk Medications in the Elderly
Care for Older Adults
Board Certification
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Appendix: Flow ChartsTypes of Case ManagementReferences
Section 6
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Behavioral Diagnosis
MHN Delegated GroupsHealth Net
Medical Diagnosis
Medical Diagnosis
Medical and Behavioral Diagnosis
Medical and Behavioral Diagnosis
SNP Case Management Flowchart
SNP Eligibility File
Health Net Types of Case Management
SNP Complex Case Management
Complex Case Management
Ambulatory Case Management
Length of Enrollment
Continuous for all SNP members
Short-term for catastrophic or terminal diagnosis
Short-term to meet coordination of care needs
Components Annual HRA Assessment Care Plan ICT Coordination of Care
Assessment Care Plan Home Visits Coordination of Care
Assessment Care Plan Coordination of Care
Identification Referral/Predictive modeling to move members betweencare levels per need
Referral/Predictive modeling – less than 1% of members
Referral/Predictive modeling – ex. transplants, maternity, hi-risk
Membership SNP Members All lines of business All lines except SNP
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Care Transitions Process
Stratification/SurveillanceCase Management
Disease Management
Pre-AuthorizationNotification of Admits in 24 Hours
Daily Admission/Discharge Reports
Prepared for AdmissionCommunicate Care Plan
Discharge Plan and Follow-Up
Prevention
Identification
Management
ImproveOutcomes
Decrease Readmits